Provider Demographics
NPI:1861171357
Name:FILL, KELLY JEAN (OT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:FILL
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:JEAN
Other - Last Name:LORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:410 ASHTON DR
Mailing Address - Street 2:
Mailing Address - City:CHESWICK
Mailing Address - State:PA
Mailing Address - Zip Code:15024-9727
Mailing Address - Country:US
Mailing Address - Phone:724-826-0153
Mailing Address - Fax:
Practice Address - Street 1:3023 WILMINGTON RD
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:PA
Practice Address - Zip Code:16105-1242
Practice Address - Country:US
Practice Address - Phone:724-656-8814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-13
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC009141225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist